This child seems to producing a dilute urine....
What is the daily fluid intake in this child? Has a
fluid-restriction been attempted to assess diabetes insipidus?
Andrew
Dr. Andrew W. Lyon, Clinical Biochemist / Home Office
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Claire Hart
Sent: April 9, 2003 10:51 AM
To: [log in to unmask]
Subject: really low Na
Dear All,
Could anybody help with a patient with very low sodiums who we can't figure
out. He is 3 and has West Syndrome (neurological condition with
epilepsy/severe developmental delay) and has had two recent admissions with
low sodiums, on admission this time his Na was 105! Results on 31/3/03 were:
Na 105 (133-144)
K 6.8 (3.5-5.4)
Cl 70 (98-111)
Bicarb 17 (19-28)
urea 16.7 (1.6-6)
creatinine 115 (23-66)
glucose = 6.7
plasma osmolality= 240
urine osmolality =207
urinary Na = <5
urinary K = 49
Random cortisol (taken while Na = 105) = 930
TFTs previously normal.
The history previous to admission was of a few days being generally unwell,
irritable and with some retching but no significant vomiting (previously
treated surgically for reflux), no diarrhoea (actually being treated for
constipation). CRP was normal. On admission he was clammy and shocked but
otherwise remarkably well for somebody with a Na of 105 -which tends to
suggest that the sodium loss has been gradual. The sodium responded well to
treatment and was normal again within 48 hours. The previous admission was
in February when results were: Na 114 K 6.3 Cl 79 bicarb 14 urea 30.2
creatine 129
There was again a similar history of being generally unwell but nothing very
specific. I should say that the potassiums may be misleading as the samples
were capilary collections and may reflect the difficulty of getting blood
from such a dehydrated child , although there was no visible haemolysis.
What we can't work out is where all the sodium is going,( and fluid for that
matter). He doesn't appear to be losing it renally -a number of urinary
sodiums have all been around 10 (when Na in ref range), and it was <5 when
the plasma sodium was 105, but there seems to be insufficient reason for
such a large extra-renal loss. He doesn't have D &V and nothing to suggest
any accumalation of intracorporeal fluid pools. The only thing that has
been noted is that he is a rather sweaty child, though nothing really
excessive. I have 2 questions really; 1. Can sweating ever cause such
excessive loss of Na?? 2. Can anybody come up with another reason for these
results? Although we have no evidence of renal loss, we have sent samples
for aldosterone/renin and for urinary steroid profile -is there anything
else we should consider. Would be most grateful for any suggestions,
many thanks,
Claire Hart
Senior Clinical Biochemist
Sheffield Children's Hospital
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